9.7.07 - Issue # 287 Forward This Newsletter To A Colleague

Carol Tekavec
CDA RDH
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Avoid These Common Coding Errors

Your patients count on their dental insurance to help them receive the dental care they want and need.  In fact, recent surveys reveal that 60% of patients, who have visited a dentist in the previous year, have dental insurance. Clearly, insurance is important to many patients, even though it was never designed to cover the total cost of dental treatment.

Whether you file claims for your patients, or they send in the claims themselves; you can help them get the benefits they deserve by using correct treatment codes and narratives. They get the best benefit possible, and your office gets paid on time!

Coding Errors Delay Claims

The HIPAA (Health Insurance Portability and Accountability Act) of 1996 mandated that all dentists and insurance carriers use the most current form of the ADA treatment codes. Right now this is the Current Dental Terminology (CDT)-2007-2008. With this in mind, here are three common coding mistakes.

  • Using D1201-Topical Application of Fluoride (Including Prophylaxis)- Child; for a child receiving a “cleaning” and fluoride treatment.  Code D1201 was deleted for 2007-2008.  Offices should now use D1203-Topical Application of Fluoride (Prophylaxis not Included)-Child in addition to D1120-Prophylaxis-Child to report a child prophy and fluoride treatment.  There is also a new code for fluoride varnish, D1206-Topical Fluoride Varnish.  This service is described as being appropriate for moderate to high caries risk children or adult patients. For quicker payment, how might you indicate “high caries risk” on the claim?  Use a narrative (section #35-Remarks on the ADA claim form) pointing out previous decay, current decay, (especially cervical caries) or other patient specific issues.
  • Using D2970-Temporary Crown (Fractured Tooth) for a temporary crown placed during crown/bridge fabrication. That type of temporary is considered to be “all inclusive” with the cost of a final restoration. Therefore, using a separate code is inappropriate. To be sure that finances are covered, any costs associated with the placement of a temporary crown while a “permanent” crown is being made, should be included in the fee being charged for the final crown. When is D2970 appropriate? Interestingly, D2970 was deleted in the CDT-2005-2006, but reinstated for 2007-2008.  It is said to apply to prefabricated crowns placed as short term restorations for teeth that have been damaged, have pulpal involvement, or have a questionable prognosis.  A “fracture” is essential to the use of the code by virtue of its description.  If your patient has these issues, the use of a narrative describing what the crown is for may prompt an insurance benefit.  For example: “#8 and #9 were injured by a thrown baseball.  Temporary crowns are being used as short term restorations until it can be determined if endodontic treatment is required.”  If a benefit is provided for D2970, there may be time limits before a “permanent” crown will be covered, (6 months, 2 years, 5 years are sample time limits).  Within the framework of these time limits, any amount paid toward the D2970 before the time “runs out” may be subtracted from the payment for a final restoration, whatever that restoration might be. 
  • Charging out a separate “exam” code when the patient receives a D4910-Periodontal Maintenance, but the dentist does not examine the patient.  While it is appropriate to file a separate exam or evaluation code and fee at the same time as D4910 when the dentist performs his/her exam, it is not appropriate as a “routine” part of the perio maintenance visit. For example, if a hygienist performs D4910, and the dentist is out of the office that day, or does not evaluate the patient that day, it is incorrect to charge out any evaluation code.  According to the ADA description, “The collection and recording of some data and components of the dental examination may be delegated; however, the evaluation, diagnosis and treatment planning are the responsibility of the dentist”.  This means that only a dentist may perform an exam. Most carriers will pay toward two D4910 procedures and two evaluation procedures of any type annually.  Most often a D0120-Periodic Oral Evaluation is covered at the same appointment as D4910.  It is very common for many periodontal patients to require more than two D4910 and two D0120 services per year.  However, any more than two are the patient’s responsibility.

Be sure that your office is using correct coding and adequate narratives. It can make a big difference in patient satisfaction and the office’s financial situation.  You might be interested in my insurance coding reference book, The Dental Insurance Coding Handbook, which features all ADA codes for 2005-2008, as well as guidance on their use, narrative language, and typical plan restrictions.  This handbook is available from McKenzie Management.

With 33 years in the dental field, Ms. Tekavec is the president and owner of Stepping Stones to Success. She is a well known author and lecturer.  She has appeared at all of the nation’s top dental meetings, as well as providing programs for local dental societies and study clubs.  Still practicing clinically, she is a consultant with the ADA Council on Dental Practice and was the columnist on insurance for Dental Economics magazine for 11 years.  She has written over 200 magazine and journal articles as well as designing a “Patient Brochure” series.

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